Provider Demographics
NPI:1831499755
Name:PROVIDENCE HEALTH & SERVICES-WA
Entity Type:Organization
Organization Name:PROVIDENCE HEALTH & SERVICES-WA
Other - Org Name:PROVIDENCE PHYSICIAN GROUP- NEUROSURGERY AND SPINE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PAYOR CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:NICHOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:QUINN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-525-6715
Mailing Address - Street 1:PO BOX 34439
Mailing Address - Street 2:
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98124-1439
Mailing Address - Country:US
Mailing Address - Phone:425-525-6652
Mailing Address - Fax:425-525-6700
Practice Address - Street 1:1330 ROCKEFELLER AVE
Practice Address - Street 2:SUITE 225
Practice Address - City:EVERETT
Practice Address - State:WA
Practice Address - Zip Code:98201-1684
Practice Address - Country:US
Practice Address - Phone:425-261-4960
Practice Address - Fax:425-225-1001
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-26
Last Update Date:2010-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207XS0117XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Surgery of the SpineGroup - Single Specialty